Submaxillary cellulitis : syn. cynanche cellularis of Gregory, angina externa, angina Ludovici, cynanche sublingualis rheumatico-typhoides

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rS3pri.it od from St. Bartholomew’s Hospital Reports, Vol. XXVI.]

EXTERNA; ANGINA LTOWICI; CYNANCHE
LINGUALIS RHEUMATICO-TYPHOIDES.

BY

W. MGER ANT BAKER.

Cases of so-called submaxillary cellulitis, although not abso-
lutely very rare, are not common ; and occurring, as they do, in
an apparently capricious manner, — several within a short time per-
haps, and then not again for a long period, are apt to be less well
known and recognised than, from their importance, they deserve.

The following case was admitted into St. Bartholomew’s Hospital,
under my care, in the present year. I extract the following brief
account from the notes.

Stephen W., aged 58, admitted into Darker Ward, June 10,
1890, dates his present illness from the extraction of a tooth, a
month ago. His neck became red and swollen, however, only
eight days ago, and has gradually got worse.

There is considerable swelling, — extending from the chin to
the upper portion of the sternum, and outwards over the sterno-

mastoid muscles and clavicles. It is red, tense and brawny ;
tender to pressure ; and there is a crackling sensation on touching
the skin, as if from the presence of air in the subcutaneous tissue.
Fluctuation can be detected^. the middle line of the neck. The
patient has some difficulty in sfi&king.

Urine acid : sp. gr. 1029. A slight cloud of albumen. Tem-
perature 101.80.

An incision was made by Mr. Lucas, the house-surgeon, in the
middle line of the neck, over the cricoid cartilage, through the
skin and subcutaneous tissue. Bus and air, of a most offensive
odour, escaped, but not in large quantity.

Boracic fomentation applied.

2/6

Submaxillary Cellulitis.

June ii. — The swelling has subsided to some extent in front
find at the lower part of the neck ; but it is still considerable below
the chin.

The patient is very restless and does not sleep well. Pulse 120.
Temperature 99.4°.

The wound was enlarged, and irrigated with an iodine lotion,
and dusted with iodoform.

On June 12th the patient became rapidly worse, with more
laboured breathing (pulse 124, temperature 97. 90), and died 011
the following day (June 13th).

Post-mortem examination. — The skin was found widely sepa-
rated from the deep fascia. The muscles in front of the trachea
seemed in a state of slough.

Veins and lymphatic glands normal; also the larynx, trachea,
oesophagus, tongue, and palate.

There was no apparent cellulitis of the mediastinum. A small
patch of lymph was found at apex of right lung. No pericarditis
or pleurisy. Heart and lungs normal.

All the abdominal viscera normal.

The following ease was admitted into Coborn Ward under my
care April 1 5. 1889.

Case II. — H. T., aet. 62, was admitted with a brawny inflam-
matory condition of the skin and subcutaneous tissue of the front
and sides of the neck, and upper part of the chest — extending
from the chin to two or three inches below the upper edge of the
sternum, and from ear to ear ; obliterating all landmarks in the
cervical region. Some pitting occurred on pressure. Breath very
offensive.

No ulceration could be detected anywhere in the mouth.

The patient seemed almost moribund on admission. Respira-
tion rapid ; pulse very feeble ; countenance dusky. He apparently
suffered much pain. Only brief notes were recorded.

Mr. Burns, the house-surgeon, made a free incision in the
middle line of the neck, from the chin to the pomum Adami, and
on each side near the angle of the jaw ; and one in the middle line
over the upper part of the sternum. .

The patient died within forty-eight hours after admission into
the Hospital ; his temperature varying from ioo° to 103° F.

Post-mortem examination. — All the soft tissues of the front of
the neck seemed in a state of slouch from the chin to the sternum,
but the jawbone and hyoid bone were not affected; nor was any
clot present in the veins.

There was general cellulitis with sloughing of the anterior

2/7

Sab maxillary Cellulitis.

mediastinum, and extension of inflammation to the pericardium,
which was roughened by recent lymph. The right pleural cavity
contained blood-stained fluid and shreds of lymph. The lung con-
tained much fluid, but there was no suppuration.

Heart very fatty. Kidneys large and fatty ; granular on the
surface. The left contained a cyst as large as a walnut. Liver
fatty and cirrhotic. No ascites. Spleen large and soft. Intes-
tines, bladder, and prostate normal.

My colleague, Mr. Langton, has kindly given me the following
notes of a very typical case of this disease, which was admitted
into the Hospital many years since, during his term of office as
house-surgeon. It illustrates particularly well one great risk at-
tending on submaxillary cellulitis, — namely, the danger of suffoca-
tion from rapidly extending cedema of the glottis.

J. A., aet. 25. Admitted February 6, 1862. When first seen
he was obviously suffering “ from a swelled neck and great diffi-
culty of breathing. On examination,” Mr. Langton says, “I
found that the glands on the left side of the neck were very con-
siderably enlarged, and there was great swelling below this and
also on the right side extending towards the mesial line. The
skin on examination was of dark purple tint, very brawny, and
here and there boggy in consistence, and higher up under the
chin there was a sense of indistinct fluctuation. The hyoid bone
and thyroid cartilage could just be felt. His mouth was open,
and on looking in I found that his tongue was pressed against the
hard palate: the tongue itself seemed to be of its natural size and
consistence, the mucous membrane, however, forming the floor of
the mouth was elevated to a level with the free edges of the lower
incisor teeth, and the tongue appeared to be pushed up by infiltra-
tion of matter under it, and thus causing the tongue to be pressed
against the roof of the mouth. It was almost impossible to obtain
a view of the condition of the fauces in consequence of the swell-
ing of the parts. His face was flushed and his lips of a dark-blue
colour, and the aim nasi widely dilating. His pulse was about 1 10
and sharp. There was great ccdema of the back part of the head,
which he said had commenced first there and then travelled down-
wards. He was a butcher by trade, and stated that he had severe
pain on the left side of head and face ; that the swelling at the
back of the head commenced about five or six days previously, and
that the glands and lymphatic vessels had been enlarged some
three or four days, and that he had been getting gradually worse.
His dyspnoea first commenced last night, when he found that he
could not breathe comfortably without being propped up in bed.”
I he patient was admitted into the Hospital, and soon afterwards

2/8

Submaxillar// Cellulitis.

the dyspnoea increasing, Mr. Langton was summoned hastily to
the ward, and found that the. patient had ceased breathing. “ His
face was perfectly livid, Ms pulse just beating, and he made one or
two spasmodic attempts at inspiration. As the only chance was
t) perform tracheotomy or laryngotomy, I immediately proceeded
to operate, making an opening as low down in the trachea as I
conveniently could, since the brawny induration extended some
distance down nearly to the sternum. On cutting through the
muscles, a considerable quantity of sero-purulent matter escaped
into the wound. The trachea was opened about half an inch
below the isthmus of the thyroid to the extent of three rings and
the largest tube introduced. The wound was about an inch and
three-quarters deep, due to the infiltration of matter. During the
operation he made one attempt at inspiration ; but before the tube
was introduced his pulse ceased beating. Artificial respiration
was tried for a short time.

“ Post-mortem examination twenty-three hours after death.

“ Post-mortem rigidity well marked. Body well nourished : great
pallor of face and neck. On making the incision from the chin to
the sternum, a quantity of sero-purulent matter, with small shreds
of dead cellular tissue, escaped. The whole of the muscles of the
neck, with trachea, oesophagus and tongue were removed. The
mucous membrane covering the hard palate and pharynx were
natural, though perhaps somewhat congested. The oesophagus
was healthy. The muscles of the hyoid bone, thyroid cartilage,
&c., were found completely infiltrated along with the cellular
tissue with sero-purulent matter and flaky shreds of disorganised
intercellular membrane. The muscles under the chin and jaw
were also similarly affected; but there the pus seemed to be more
healthy. On opening the trachea, the rima glottidis was found
nearly closed, with effusion of semi-purulent matter into the sub-
mucous tissue; this extended to the epiglottis, which was also
cedematous, but not to the same extent as the rima; the effusion
did not extend below the vocal cords, although the mucous mem-
brane was somewhat congested, with some frothy mucus adher-
ing to it.

“ The glandulce concalenatce were much enlarged, as were also
the submaxillary and parotid glands, but chiefly on the left side.
The uvula was very cedematous. The bronchi were somewhat
congested throughout their whole length. The lungs were normal,
with the exception of numerous ecchymoses towards the base of
the,lungs, chiefly of the right. The heart natural; some athero-
matous deposit on the attached margins of valves (aortic) and
also the aorta. Liver congested; bile dark and viscid. Kidneys:
left was much congested but otherwise apparently natural; right

t '

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Submaxillary Cellulitis. 279

kidney not so congested. Spleen somewhat enlarged. In the scalp
over occiput there was great oedematous infiltration.

“ The brain was not allowed to be examined.”

The following case, recorded by Mr. Bickersteth,1 illustrates
also well the progress and frequent method of termination of the
worst examples of this disease.

“Until the year 1861,” Mr. Bickersteth remarks, “I had never
seen, or at least had never recognised, a case of this kind, but then
one presented itself here under circumstances that I cannot forget.

“A man, aged 40, walked up to the Hospital one morning and
requested admission. He spoke with great difficulty and indis-
tinctness, so that it was impossible to obtain much information
from him. His breathing was embarrassed. There was great
swelling beneath the jaw. The floor of the mouth was raised,
and the tongue pushed upwards and backwards against the roof
of the mouth, so that no examination of the fauces could be
made. Mr. Nash, who was the house-surgeon at the time,
recognised the peculiarity aud urgency of the case, and very
properly requested my immediate attendance. In the meantime
he ordered the man some stimulants and sent him to bed. I
happened to be at home, and came up at once, when I was
informed the patient had died suddenly a few minutes before.”

According to the notes drawn up by Mr. Nash, the patient
had been seized with rigors and severe pain in the submaxillary
region about three days only before his admission, and these
symptoms were shortly followed by swelling, which extended
from the lower jaw to the upper part of the sternum. “ The
pomum Adami and trachea were completely obscured. The skin
was tense, but was neither changed in colour nor consistence, nor
were its movements upon the sub-structures more interfered with
than the tension would account for.”

“Autopsy. — Shortly after death, puncture w7as made with a
tenotomy knife into the floor of the mouth, when a small quantity
of air and some sero-sanious fluid escaped.”

“All the muscular interstices and the connective tissue sur-
rounding the trachea were infiltrated with a sero-purulent fluid,
extending upwards to the root of the tongue and downwards into
the anterior mediastinum. The submucous cellular tissue was
also similarly affected, producing anteriorly the sublingual dis-
tension already alluded to, and posteriorly oedema glottidis and
general oedematous laryngitis.”

Although submaxillary cellulitis, in its graver forms, seems

1 Clinical Lecture, published in Liverpool Med. aud Sur Rerorts, vol. iii.

p. 98.,

Submaxillary Cellulitis.

280

to be of necessity fatal, and, from its proximity to the larynx,
must be always more or less perilous, cases less virulent may be
expected to get well, especially if proper treatment be promptly
adopted. Many such cases have been recorded.

The following may be taken as an excellent example, both of
recovery, and of the line of treatment most likely to give relief.
It forms the second of the cases recorded by Mr. Bickersteth.1

The patient was a lady aged about fifty, under the care of Mr.
Parke of West Derby, who began to suffer from feverish symptoms
and pain beneath the lower jaw about five days before Mr. Bicker-
steth saw her in consultation.

At this time there was considerable diffuse swelling of the
whole of the anterior and lateral parts of the neck, “so that the
space between about an inch below the chin and the sternum
presented a decided convexity. The swelling extended laterally
on each side to the parotid space ; above, it was limited by the
base of the jawbone. Below it gradually subsided over the
upper part of the sternum and inner third of the clavicles, which
were lost in the general tumefaction. The skin of the neck was
everywhere of a bluish dusky colour, but not inflamed nor
thickened, nor cedematous.” . . . “ On examining the state of the
mouth, which was accomplished with some difficulty owing to
the patient being unable to separate the teeth beyond a very
limited extent, the raucous membrane of the floor was found to
be raised to a level with the top of the lower teeth, of a deep
purple colour, and cedematous. The tongue itself was not en-
larged, but pushed upwards and backwards towards the back of
the mouth. O11 feeling the floor of the mouth, it felt soft and
yielded readily to pressure, but I could not detect fluid, either with
the finger in the mouth, or assisted by the hand pressed on the out-
side at the same time ; neither could I feel from within the firm
resisting swelling in the submaxillary space which I felt outside.”

The treatment adopted in this case by Mr. Bickersteth was to
“make an incision exactly in the median line, commencing about
an inch from the point of the chin downwards to the extent of
between three and four inches. I divided the skin and fascia in
the first instance, and then carefully and slowly cut deeper, keep-
ing exactly in the middle line through hard dense structures to
the depth of at least two inches. Then, introducing my fore-
finger into the wound at its upper part, I found I had cut through
the wdiole thickness of the induration, and that I had entered a
cellular space beyond. Putting a finger of the other hand into
the mouth, I was satisfied I had divided everything, except the
mucous membrane of the floor of the mouth.”

1 Loc. cit., p. 99.

Submaxillqry Cellulitis. 281

... “No pus or serum was seen to flow from the incision,
and as I had only cut entirely through the induration at the
upper part of the incision, I then made the wound of equal depth
throughout ; but still I did not see any matter flow.”

The treatment was followed by the happiest results ; the patient
ultimately recovering.

Of four other cases, recorded by Mr. Bickersteth, two died, —
both from asphyxia ; and two recovered, after free incision, as in
the case just related.

There is no reason, I believe, for assuming that submaxillary
cellulitis is different, in any essential features, from cellulitis as it
is frequently met with in other parts of the body. In its gravest
forms cellulitis may be a fatal disease, in any part of the body
and under any treatment. The special importance of a knowledge
of the usual course of submaxillary cellulitis lies in the urgency of
the disease, on account of its neighbourhood to important struc-
tures ; and especially in the imminent danger, in many cases, of
suffocation, from oedema and spasm of the glottis, if the tension
be not promptly relieved.

Regarding the method of treatment to be adopted in cases of
submaxillary cellulitis, it may be observed that while, of course,
free incisions are necessary wherever any signs of fluctuation are
present, and where incisions can be safely made, these must not
be delayed where no signs of fluctuation exist. In other words,
the treatment of cellulitis in the neck must be the same as that
of the like diseas6 in a limb ; and if any difference be made, it
must be in taking still more prompt measures in the cases now
under consideration on account of the greater danger of delay.
With reference to this point I cannot do better than quote again
from Mr. Bickersteth’s clinical lecture.1

“In the early stage of this affection,” Mr. Bickersteth says,
“when the swelling has only existed a few hours, ora day or two,
when there is no great difficulty in swallowing or in breathing,
when the tongue is not pushed up materially, nor the roof of the
mouth raised, do not suppose I would at once advocate an opera-
tion. A milder treatment may then be tried ; the application of
leeches over the tumefaction, a sharp aperient, such as calomel and
jalap, and soothing applications and fomentations, or linseed
poultices.” . . .

“The incision,” if required because milder methods have failed,
“to do good, should go fairly through the whole thickness of the
inflamed textures ; and where can we do this with safety except in
the median line ? Only there can we divide the textures without
dividing important blood-vessels and nerves. Thus' although the

1 Loc. cit., p. 107.

282

Su b maxillary Cell uli Us.

swelling may be chiefly on one side, we make the incision in
the middle, its deepest part reaching inwards towards the epig-
lottis ; and although the most intense inflammation may not be
here, we approach the part where its consequences are most to
be feared, and afford a free exit for the discharge of inflammatory
fluids.”

Mr. Croly, in a very interesting paper in the Dublin Quarterly
Journal of Medical Science Q deals especially with the question
of treatment in cases of cellulitis of the neck. His paper, like Mr.
Bickersteth’s, will well repay perusal.

Regarding the general or constitutional treatment of cases of
submaxillary cellulitis, it is not necessary to say anything in this
place, as it differs in nowise from treatment of the like disease in
other parts.

The name by which the several forms of snbmaxillary cellulitis
have been chiefly known of late years (angina Ludovici) is an un-
fortunate one. It has the disadvantage, common to all cases in
which a disease is named after its supposed first observer, of giving
no clue to the nature or site of the malady ; and, in this instance,
the term is not appropriate in any sense, inasmuch as Ludwig of
Stuttgart, after whom it is named, was not the first author who
described it. His description of the disease, for which he pro-
posed the term “gangrenous induration of the cellular tissue of
the neck,” appeared in the year 1836 ; but a well-marked example
of the affection had been recorded some years previously (1822)
by Dr. Gregory.

The case is recorded in the London Medical and Physical
Journal 2 and the disease would appear to be then (1822), as now,
comparatively rare. For Dr. Gregory remarks, “ It has never
occurred to myself to witness anything at all similar to it, either
before or since, nor have I been able to ascertain that in the
practice of any of my professional friends, one analogous case
has ever presented itself. The disease consisted in an extensive
inflammation of the cellular membrane of the neck and anterior
mediastinum, of a highly malignant character. Its course was
rapid, and the symptoms which attended it were of unusual severity.
It bore, in the first instance, the appearance of a rheumatic affec-
tion of the joints of the cervical vertebrae. At a somewhat later
period of the disease, it was imagined that the thyroid gland was
the immediate seat of the inflammation ; but it was not until after

1 1873, vol. i. p. 401.

2 The London Medical and Physical Journal, vol. xlviii., July to December
(1822), p. 287. “Case of Cynanclie Cellularis with Remarks. By George
Gregory, M.D., Physician to the Small-Pox Hospital, and one of the Physicians
to the St. George’s and St. James’s General Dispeusary.”

Sub maxillary Cellulitis. 283

death that the exact nature of the case was understood. Books
have afforded us but very scanty information concerning this
affection.” . . .

“Ann Jones, 25 years of age, housemaid, was attacked on
Tuesday, February 13, 1821, with feverish symptoms and pains of
the back part of the neck, resembling rheumatism. She was not
conscious of having exposed herself in any particular manner to
cold. For these complaints she was bled, the same evening, to
the extent of a pint, and took opening physic. The following
day she came under my care ; and at two o’clock P.M., when I
first saw her, the following was the state of her symptoms.

“ She had a considerable degree of fever, attended with great
difficulty of swallowing. There was swelling, hardness, and some
tenderness of the external parts of the throat. The swelling and
tenderness extended round the neck on each side, but were chiefly
felt and complained of at the junction of the clavicles with the
sternum. On inspection of the internal fauces, no enlargement
of the tonsils, or redness, or ulceration of the membrane of the
palate and pharynx, were perceptible. There was no hoarseness,
and scarcely any degree of difficulty of breathing. No essential
relief had been obtained either by the bleeding or purging. It
was observed, on the succeeding day, that the swelling and tender-
ness of the throat had augmented, but the febrile’ symptoms con-
tinued nearly the same. During the night the difficulty of
deglutition increased, and the breathing became for the first time
impeded. She was bled from the arm the following morning to
sixteen ounces, and the blood appeared buffy but not cupped.
The relief afforded by this measure was, however, very trifling.
At this period I was favoured with the assistance of my friend
and colleague, Mr. Jeffreys, and we had soon an opportunity of
observing the rapid strides with which the disease advanced.
Mucus began to collect in large quantity about the glottis, and its
expectoration occasioned extreme pain. The difficulty of breath-
ing increased to so great a degree, that the tongue assumed a blue
colour. To relieve this, blood was twice drawn from the arm,
but the alleviation was very momentary. The blood, when drawn,
had a very dark appearance. The difficulty of swallowing became
speedily so great as to preclude all possibility of administering
remedies by the mouth. Leeches and fomentations were had
recourse to. Latterly the patient complained of very considerable
pain, referred to the top of the sternum. After a great deal of
suffering, she died on Monday, February 19th, seven days from
the invasion of the disease.

“The body was opened on the following day, in the presence of
Mr. Jeffreys and a number of other gentlemen, whom the singu-

284

Submaxillar y Cellulitis.

larity of the case had attracted ; and the appearances which pre-
sented themselves were these : —

“The cellular membrane beneath the shin of the throat and
around the trachea, as well as that which connects the pharynx
and palate to the surrounding bones, was everywhere in a state of
disease — doubtless the result of inflammatory action. In some
places, actual sphacelus had occurred ; in others, it was in a state
of what might be called imperfect suppuration. In one or two
points, purulent matter was distinctly to be traced. The same
disorganised condition of the cellular membrane pervaded the
whole extent of the anterior mediastinum, even as low as the point
of the ensiform cartilage.

“While such was the state of the cellular membrane of the
throat, the mucous expansions of the palate, pharynx, oesophagus,
and trachea were healthy, except in so far as they were covered
with a preternaturally abundant secretion of mucus. The lungs
and the different abdominal viscera were found free from any
traces of disease.

“ To this singular variety of quinsy I have ventured to apply the
term cyUanche ccllularis, from a belief that it has not yet received
anymore appropriate appellation. An extensive acquaintance
with the works of the old authors might possibly have furnished
me with cases offering an exact parallel to the one now detailed,
but hitherto I have only succeeded in detecting one or two, which
appear to resemble it in some of its characters.”

Dr. Gregory then refers to the fact that Mr. James of Exeter
had described a disease under the title of “ angina externa,”
exhibiting the following symptoms : —

“ The patient,” he says, “ (perhaps a female), of unhealthy and
generally full and gross habit, has a swelling deep-seated in the side
of the neck, towards the angle of the jaw, causing a great degree
of pain in that side of the head, from its effects upon the nerves of
the part most probably, and accompanied with much pyrexia.

“There is loading of the cellular membrane, similar to that
which we observe in erysipelas phlegmonodes, but well limited,
firmer, and more prominent. This takes place to a great degree,
and the result is that the patient is scarcely able to swallow fluids,
breathes with great difficulty, and cannot sleep from the impending
suffocation. After a time, the skin adheres and inflames, and
thickens as it inflames, but does not point, or for a long time
show any symptoms of pointing, or giving way by slough or
ulceration; meanwhile sloughs and noisome pus have formed
underneath, and do great mischief.” 1

1 JiiiiH's on Inflammation, p. iSS.

Submaxillary Cellulitis. 285

Dr. Gregory also refers to a case previously recorded by Dr.
Kirkland1 (who had applied to it the name by which Mr. James
designates it, “ angina externa ”), and remarks concerning it,
that it approaches more nearly than any he had yet met with to
the subject of his paper.

“A fjentleman had a swelling with inflammation near the edge
of the lower jaw on the right side of the throat, which soon
extended itself to the other side, and became so great that we had
just reason to apprehend his being suffocated, if it continued to
increase in size much longer ; for it had already affected his
breathing violently ; and he luas almost choked ivith phlegm,
from pressure upon the windpipe. It had the appearance of
suppurating, and a small quantity of matter seemed to fluctuate
under the teguments, but so very deep that we durst not think of
cutting into the side of the throat, where it was perceived, on
account of the carotid artery. However, as no time was to be
lost, I was determined, if possible, to make a drain from the
part; for which purpose I made an incision at the lower part of
the tumour, in the middle betwixt the sterno-hyoides, and was
fortunate enough to reach the matter that had formed. Its
gradual discharge put the patient out of all sort of danger, but
the hardness was troublesome, and long in being subdued.”

The only other case referred to in Dr. Gregory’s paper is one
recorded by Dr. Wells. Dr. Gregory does not quote the case at
length, but merely refers to it as resembling his own case after
those already mentioned, more nearly than any other. The case
is, however, interesting and very nearly allied, if not identical
witfT the disease described by Dr. Gregory; and I shall be for-
given, therefore, I hope, for extracting at length Dr. Wells’s account
of it from the Transactions in which it is recorded.2

“A Case of Extensive Gangrene of the Cellular Membrane be-
tween the Muscles and Skin of the Neck and Chest. By William
Charles Wells, M.D., &c. Bead May 2, 1809.

“ Mrs. G., the wife of an inferior tradesman in London, had
always from her birth been rather feeble, but had never been
afflicted with any considerable disease, prior to that which I
am about to describe. She was married when about twenty-
two years old, and, twelve months after, brought forth a healthy
child. She soon recovered her ordinary state of health, and was
sufficiently strong to suckle her infant, which throve under her
care. About two months after her delivery, she began to feel
a pain in her bosom and collar-bones, and to be often chilly.

J Kirkland’s Enquiry into the Present State of Medical Surgery, vol. ii. p. 159.

Transactions of the Society for the Improvement of Medical and Chirurgical
Knowledge, vol. iii. p. 360. 1812.

286

Sab maxillary Cellulit is.

These ailments were attributed to her staying much in a room,
the door and windows of which were frequently open, though the
weather was cold, to prevent the chimney from smoking. About
the same time also her milk began to be less abundant ; but she
still continued to suckle her child. She remained in this state
about three weeks, at the end of which time a slight cough
attacked her, and her left cheek began to be painful, red, and
swollen. This disease of the cheek was at first thought to arise
from a bad tooth, but as it increased quickly, an apothecary was
sent for on the 20th of last March, about three days after the
commencement of the swelling. The swelling and redness had
now reached the left clavicle ; but as the system was very little
disturbed, the apothecary conceived that those symptoms depended
upon an inflammation of the parotid gland. Between the 20th
and 25th the disease spread over the whole front and sides of the
neck and chest, and in the same interval her pulse became very
frequent, and her breathing very laborious ; her cough, however,
was but little troublesome. I visited her for the first time on the
evening of the 25 th. The swelling of the left cheek, with which
the external disease had commenced, was by this time much
diminished, and the cuticle there was falling off. The swelling
of the neck was inconsiderable, as was that of the chest, except
near the upper extremity of the sternum, where was an elevation
of the skin crossing the sternum at right angles, four inches long,
an inch and a half broad, and an inch high. This evidently con-
tained a fluid, but the kind was not easily ascertained, for the
fluid very readily yielded to pressure, and there was a feeling
experienced, when the tumour was touched, similar to that given
by parchment, or a dried urinary bladder. The apothecary had
hence imagined the tumour to contain air; but the same feeling
was perceivable in every part of the diseased skin below the
tumour, and was most remarkable where the disease was most
recent. When the diseased skin was pressed, the patient felt
pain, but in no great degree : I pressed it, however, very gently.
Its colour was a less bright red than that of a phlegmon or
erysipelas. A little above the left breast, a piece of skin, about;
half an inch in length, and a quarter of an inch in breadth,
was smoother than natural, and of a brown colour, resembling
somewhat an eschar produced by caustic ; but there were no
vesicm upon any part of the skin. The disease of the skin
terminated rather abruptly, and a finger could be insinuated a
little way under its edge, which felt hard. This was the case
at least at the lower part of the chest, where the experiment
was made. Her pulse was 136 in a minute, and not feeble;
her tongue was moist, and covered with a smooth pellicle of a

Submaxillar ij Cellulitis.

287

light brown or greyish colour. She swallowed with difficulty,
and could not open her mouth sufficiently to allow me to examine
upon what this depended. Her body, which had been before
bound, was now loose, in consequence of her having lately taken
some medicine to render it so ; the matter discharged by stool
was said to be of a dark colour, and of an highly offensive smell.
The urine was said to be high-coloured, but sufficiently copious.
She complained that a little wine, which she had lately taken, had
heated her. I was told that she had been several times delirious
at night : her mind, however, when I saw her, appeared to be
altogether sound.

“ I visited her again on the 27th of March, soon after mid-day.
The redness and swelling had extended, since my former visit,
over the upper part of the abdomen. The tumour on the upper
part of the chest had also increased, and the skin which covered it
had become soft, so that there was now 110 doubt of its contents
being liquid. The pulse was 150, and feeble; the breathing was
more laborious, and the inside of the lips was covered with
aphthae. She was still, however, free from delirium. No discharge
by stool had taken place for nearly two days. She afterwards
gradually became weaker, and died in the forenoon of the following
day, her mind having remained to the last almost entirely undis-
turbed by delirium.

“As I had never seen such a disease before, I applied for leave
to inspect the dead body, which was granted with reluctance.
The inspection took place about ten hours after death. The
tumour over the sternum had been previously broken by some
accident, and, from the report of the nurse, nearly a quart of a
dark and highly foetid fluid had issued from it. The skin of the
neck and chest had entirely lost its redness ; its colour now was a
dirty white, except in a spot upon the left side, above two inches
square, which was of a dark blue. When an incision was made
through the skin of the thorax a very foetid liquor of a dark-brown
colour flowed out, the quantity of which, together with what was
afterwards removed by sponges, was estimated to exceed a pint.
Upon turning the skin aside, a most hideous sight presented itself,
the whole cellular membrane, which covered the muscles upon the
fore part and sides of the neck and chest, being discovered to be in
a state of gangrene. But the muscles themselves, though immedi-
ately beneath the gangrenous membrane, and the glandular sub-
stance of the mammae, which was nearly surrounded by it, seemed
free from disease. Nothing extraordinary was found in the chest,
except an ounce or two of watery fluid in the left cavity, and a
slight redness in the anterior portion of the pleura costalis. The
great difficulty of breathing, therefore, under which the patient

288

Su bmaxillary Cellulitis.

liad laboured, probably arose from her suffering an increase of
pain, when she attempted to use the muscles contiguous to the
external disease. In bringing together the divided portions of
the skin of the chest, its texture, in several places, was found too
weak to retain the thread, which was employed for this purpose.
No part of the body was examined besides those which I have
mentioned, chiefly by reason of the repugnance of the relations,
one of whom was present during the inspection. But had I then
thought of it, I should have endeavoured to ascertain by what
mechanism the foetid fluid had been prevented from entering the
surrounding healthy cellular texture, while it seemed to flow freely
through such parts of that texture as w7ere diseased.”

, ‘ ...

I was not aware, when I determined to record some cases
of submaxillary cellulitis in our Hospital Reports, of the volu-
minous extent of the literature which exists on the subject. A
large number of cases of the disease have been placed on record,
but they are for the most part scattered in the pages of various
journals, and Transactions of Medical Societies, British and Con-
tinental, and therefore not for all very accessible.

It was not, moreover, until a great part of this paper was
written, that I found the subject had been very fully treated, from
the historical point of view, by Mr. R. W. Parker in a very
interesting article in the Lancet, vol. ii ., 1879.